Introduction – Difficult Airway

Airway management challenges are the common causes of morbidity and mortality of patients acquiring anesthesia during operation. Airway management is the integral part of general anesthesia that allows ventilation and oxygenation in patient. The prime purpose of airway management is to stabilize and secure the patient during an emergency or operation. Pre-operative assessment of respiratory tract should be done through identification of patient’s relevant factors via standard diagnostic measures prior to anesthesia. This help to evaluate the degree of difficulty with mask ventilation and endotracheal intubation.

00:06
So we're now going to talk
about my nightmareand the nightmare of virtually every anesthesiologist.
And that's the failure to secure the airway, becausethis can lead to death, can lead to immediate
cardiac arrest, and it can lead to permanentbrain damage, chronic vegetative
states, from cerebral hypoxemia.
00:30
This is the single most important aspect
of the anesthesiologist's job.
00:36
And really, it's what we get paid for.
If we fail in this respect, we failed in everyrespect, because obviously, if the patient doesn't survive
the anesthetic, having surgery is kind ofa waste of time. We're going to talk more
about standard intubation techniquesand techniques used in the difficult airway
situation, in Lecture 5, under Generalanesthesia. But some of the warning signs,
just to give you a preview of what's going to happen,include poor mouth opening; normally
a mouth should open 5 - 6 centimeters, butif it only opens less than 2 - 3 centimeters,
that's a warning sign. Poor neck mobility. So,the inability to extend the neck
is a major concern andit's common in elderly people.
So we see it a lot. Small or deformedmandible. This can happen in congenital anomalies,
it can happen with damaged mandibles, it can happenwith people who have very poor dentition,
and have a large overbite and a poorlydeveloped mandible as well. We mentioned
we measure the mento-thyroiddistance, which is the distance from the tip of the chin
to the thyroid cartilage, which is the large cartilage inthe neck, the airway. And if it's less than 4 centimeters,
we know we may have a problem.
02:00
Short, thick neck can be a problem.
Fixed flexion deformity of the neck,as seen in some diseases such as ankylosing spondylitis,
and anything that interferes with normalairway throughput, such as a tumor,
an abscess or hematomata, can all leadto difficult airway situations. Most anesthesiologists
take the view that we should alwaysbe conservative when approaching the airway.
And if there's any doubt that wecan get a tube in, in the patient, asleep and paralyze,
then we shouldn't put them to sleep, and we shouldn't paralyzethem. We should do an awake intubation. Now,
awake intubation sounds like a terrible technique,I can just see all of you gagging, and thinking all kinds
of horrible things about the person who would subjectyou to this. And it sometimes isn't very pleasant,
I'll be very honest about it, but it is the absolutebest way to prevent failure in intubation.
Because the patient is awake and maintainshis or her airway through the whole
procedure. So basically, if youare concerned about getting a tube in, or you think
it isn't going to happen, then you should definitely doan awake intubation. There are other
techniques that allow us to makesomewhat difficult intubations easier.
And these include airway adjuvants availableto use immediately. A stylet,
which is a malleable devicethat goes through the tube and gives the tube shape.
A bougie, which is an even longer device which also canbe passed down through the, through the cords, even
in a situation where it's very, very difficult to see the cords,and then the tube can be passed down, the endotracheal
tube can be passed down over the bougie.
03:48
Video-laryngoscopes actually allow us
to use a screen and see exactlywhere we are. The laryngeal mask
airway is a device that allowsus to, in certain circumstances, intubate
through the LMA and secure the airwaythat way. And then, if worse comes to worst,
we have to do a surgical airway. And for thatwe need to have a crico-thyrotomy kit immediately available.
And most of us dream that we'll never do this, andas of this moment, and I'm pushing my luck here,
I have not had to do this.
04:24
You should always keep 'difficult intubation' kit
immediately available in the operating room area.
04:30
It doesn't have to be in every operating room, but it needs to be nearby.
And you need to have a portable kit, because anesthesiologistsget called all over the hospital to secure
airways in people that other peoplehave, other physicians have failed to secure. So,
emergency room, tents of care unit, cardiac arreston the wards. We get called to these on occasion simply
because our colleagues and other specialists have failedto intubate the patient. There's
a “difﬁcult airway” algorithm. MostAnesthesiology Societies have
a 'difficult airway' algorithm.
05:06
The American Society of Anesthesiology has a very
extensive one. The only negative thing I can say about itis, it's probably too extensive, it's hard to memorize.
The Canadian Anesthesiology Societyhas a very simple algorithm. It may be too simple.
The UK has the Difficult Airway Society,which is a society that is devoted to coming up
with better ways of dealing with difficult airways.
05:30
And one should definitely look at their web page
and be prepared to deal with a difficultairway. So if, be prepared in any
difficult airway to call for help,and to call for help early! Get people in there to help you.
Because, if you don't call for help, and youget into a situation where you cannot intubate
the patient, you may be responsible for that patientnot surviving.

About the Lecture

The lecture Introduction – Difficult Airway by Brian Warriner, MD is from the course Anesthesiology: Introduction.

Included Quiz Questions

Warning signs of potentially difficult airway include:

Small mouth, flexion deformity of neck, small or deformed mandibe.

Clicking of the temporal-mandibular joing.

Slight reduction of neck flexion.

A family history of difficult airway.

Author of lecture Introduction – Difficult Airway

Brian Warriner, MD

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